Addressing threats to health care's core values, especially those stemming from concentration and abuse of power. Advocating for accountability, integrity, transparency, honesty and ethics in leadership and governance of health care.

Monday, March 09, 2009

The Color of Money: What Sort of School Doesn't Pay Its Faculty to Teach?

A letter to the NY Times by Dr Daniel Becker in response to the recent controversy at Harvard Medical School over financial relationships among industry and faculty (see our post here) brought up an interesting point:

I take issue with the implicit assumption that faculty members who accept drug money are driven exclusively by greed; this issue is much more complicated than it may seem at first.

Harvard Medical School’s 'drug money' problem relates, in part, to a little-known fact: Harvard rarely pays the salaries of its medical faculty directly. Despite substantial revenue from tuition, most faculty members teach medical students on a volunteer basis.

Similarly, the salaries of research faculty are not paid by Harvard, but rather by grants from the National Institutes of Health, private foundations and in some instances, grants from pharmaceutical companies. If these financing sources dry up, professors are often forced to find a new job.

Wait a minute, it's a medical school, so shouldn't the faculty be paid to teach and do research? That's what faculty are supposed to do.

The above letter, although it may be a bit simplistic, fits in with other anecdotal evidence that, in fact, medical schools do not pay faculty much to teach or do research. Instead, they are mainly tasked with raising money from external sources to "cover" the academic work one would think should be central to their jobs. Failing that, they must bring in fees for their clinical work.

In 2005, we quoted the editor of JAMA as saying, "few medical schools provide adequate, if any, reimbursement for teaching time."

In 2007, we noted that it was news when Harvard Medical School pledged to actually start paying hospital-based faculty meaningful amounts for teaching medical students. Previously, they were paid an average of $30/hour for doing so. However, I have not seen any follow-up as to whether the school carried out the promise. Moreover, at that time, we noted that Harvard required its faculty "to teach or volunteer on committees 50 hours a year, but Harvard does not track how many hours doctors teach and does not actively enforce the policy." Again, one might be forgiven for thinking that a faculty member generally should spend a substantial amount of time teaching. But at Harvard, they only apparently need to spend about 2% of their time doing so.

Later in 2007, we discussed a medical school dean's revelation that his school primarily judge faculty was by how much external funding (grants, contracts, practice income, etc) they brought in, not by how well or how much they taught, or the quality and quantity of their research.

Finally, in 2009, we discussed how two-thirds of the salary of one university president seemed to come from his medical school, even though that school accounted for only one-eighth of his students.

Putting it all together, it seems that the "faculty" at some, maybe most medical schools are not faculty in the ordinary sense. There is little expectation that they teach. Instead, they are supposed to do research funded by external grants, or failing that, collect fees from direct patient care. They are judged by how much money these pursuits provide, not by the quality of their research, and certainly not the quality of their teaching. The money they provide disproportionately goes to fund parts of the university outside of the medical schools. Presumably, the pressure to bring in ever more money drives "faculty" entanglements with pharmaceutical, biotechnology, device and other corporations. If one must constantly pursue grants, now mostly available from industry, one must constantly interact with industry representatives. Under this sort of pressure, is it any wonder that "faculty" might find it hard to turn down consulting work, speakers' fees, and offers to serve on advisory boards from the same people they must please to obtain grants?

So I believe Dr Becker is right. The problem is simply not the greed of "faculty" members (although some, of course, can become greedy.) Much of the problem appears to be the greed of university administrators who see their medical schools and academic medical centers as cash cows, and see nothing wrong with hiring "faculty" who scarcely teach, as long as they keep bringing in the cash.

It is astonishing to me that so few seem to grasp the connection between an academic culture in which it is the generation of revenues that is paramount (above activities like teaching, publication, and even clinical services if the latter are not maximally reimbursable) and the extensive problems we have with COIs.

Perhaps it is because I am heavily disposed to think socially and culturally in thinking about health and illness, but I think it is a terrible sign of the quality of our discourse on COIs that so few seem to grasp the (to me, obvious) connection between the ethos and culture we actively create in AMCs and our serious problems with COIs.

You are one of the few bloggers I see consistently pointing out the connection, which I am beyond pleased to see. Really, I think about it in this way: these days at an AMC, one can be a gifted teacher (winning awards, residents love em), a gifted academic (writing and publishing in the best journals) and even a gifted clinician (say a family medicine doctor), and if one is not generating revenue, that is good enough to get you shown the door in a few years.

To put it in professional ethics terms, that is a !@#$ed-up state of affairs.

Sadly, this practice is not confined to medical schools. Most university-based schools of nursing expect faculty to bring in big bucks via grants, even when the total sum of available money is far smaller than the sums needed to support faculty. Granted, most nursing faculty are paid salaries; nurses historically have not been supported in generating fees for delivering their services. The same thinking, though, is prevalent. Teaching seems to be an afterthought and teaching undergraduates is seem by many nursing faculty as a trial to be endured. Graduate students, especially doctoral students, are preferred. We wonder, then, why we have a shortage of people wanting to work in these environments.

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